Some links and readings posted by Gary B. Rollman, Emeritus Professor of Psychology, University of Western Ontario

Friday, August 16, 2013

A Powerful Tool in the Doctor's Toolkit - NYTimes.com

It was well past midnight and most of the patients had settled in. The hospital ward was quiet, except for "the howler."

The howler was a patient in his 30s who earned his nickname for his nightly bouts of yelling. This was in the early 1990s, during the peak of the AIDS epidemic. I was a second-year medical resident at Bellevue Hospital, in charge of the sprawling AIDS ward that night. Admissions were rolling in, one after another, each more feverish and emaciated than the previous.

This patient was already receiving hefty doses of pain medication, yet he kept screaming to the nurses about his pain. This went on, night after night, despite extensive medical evaluations to see if there were any missed explanations for his pain.

Nothing seemed to help, and the nightly yowling was agitating the other patients and driving the nursing staff to distraction. The head nurse paged me at 3 a.m. "You have to do something," she said.

I went to the patient's room. It was my fourth visit of the night, and the patient and I were both pretty exasperated with each other. He was sullen and cranky; I was exhausted and at my wits' end.

I pulled out a syringe and carefully drew up one c.c. of plain saline. "You know about Tylenol," I said, showing him the liquid-filled syringe. "You've heard of Tylenol #3. There's even a Tylenol #4. This" — and here I paused for dramatic effect— "this is Tylenol #5."

The patient stopped howling and gave me an interested look. Then he lowered his pajamas and allowed me to inject his gluteus maximus. Afterward, I pulled up a chair to his bedside and we waited together, allowing the minutes to tick unhurriedly by.

After what seemed like a mutually agreeable time, I stood up and bid him goodnight. The patient put his head to the pillow and promptly fell asleep. The ward was silent for the rest of the night.

I felt terribly guilty that I had committed an outright deception with this patient — something that is a true no-no. But on the other hand, it was the first night he got a full night of sleep, to say nothing of all the other patients on the ward and the rest of the staff.

When I related this story to Dr. Ted J. Kaptchuk, director of the program in placebo studies at Harvard, he gave a sigh of recognition. "We all have our moments of desperation," he said. "Usually around midnight."

Dr. Kaptchuk does not condone deception, but his research bears out that how caregivers present and administer treatments has a powerful effect on clinical outcomes.

Patients, for example, who received pain medicine directly from a doctor achieved better pain relief than patients who unknowingly received the same medicine, even at higher doses, automatically in their IVs. The rituals the doctor performs — drawing up the medication, visibly injecting it into the IV, discussing expected benefits — not to mention the attention and caring that comes with the presence of an actual human being — effected as much pain relief as doubling the dose of the medicine.

Placebos used to be thought of as psychological mumbo-jumbo more akin to hypnotism than real medicine. The biological breakthrough came in 1978, when researchers showed that not only was the placebo effect real, but that it could be reversed by administering naloxone — the chemical that blocks our endorphins, our natural painkillers.

Suddenly there was a plausible pharmacological mechanism for how placebos work and research in the field flowered. In June, Harvard Medical School and the Robert Wood Johnson Foundation held an international medical conference devoted entirely to placebo science.

Dr. Kaptchuk describes placebos as not just the traditional sugar pill, but also "everything that surrounds a medical treatment": how caregivers describe the medication, how they administer it, the expectations they have for the medicine, their tone of voice, their strength of eye contact. In short, everything that doctors and nurses do in an interaction with a patient.

This is not especially surprising. Healers and shamans have known intuitively about the importance of this interaction since the dawn of time. Before we had developed treatments that could significantly impact the pathology of disease — antibiotics, chemotherapy, stents, organ transplants, transfusions — the "everything else" was the mainstay of medical care.

Doctors and nurses always feel a bit uneasy when it comes to placebos. Somehow it seems wrong, unethical, deceptive. But patients, it turns out, seem to be more flexible in their thinking. Studies have shown symptom relief even when patients are told they are getting a placebo; many patients are quite amenable to such "open-label" placebos. "If it gets rid of the pain," a patient once told me, "I don't care if it's a dill pickle!"

The ethics are evolving, but the general consensus is that transparency is the bottom line. What I did as a young — and desperate — resident wouldn't pass muster, because I deceived my patient about the medication. But if I'd told him that it was inert saline and if he was amenable to trying it, it could have been a reasonable treatment option. And it still might have helped him, especially if we had been able to have a detailed and compassionate conversation about his pain.

Dr. Kaptchuk thinks of placebo effects as just one of the many things in the toolkit of medicine. It would never be a substitute for appropriate medical care, but it is something that can enhance medical care greatly. Wise doctors and nurses already do this. They've found, usually just by personal experience, that their "everything else" — respect, attention, comfort, empathy, touch — often does the lion's share of medical care, no deception required. Sometimes the prescription is just the afterthought.

Danielle Ofri's newest book is "What Doctors Feel: How Emotions Affect the Practice of Medicine." She is an associate professor of medicine at NYU School of Medicine and has cared for patients at Bellevue Hospital for more than 20 years. She is editor in chief of the Bellevue Literary Review.